Knee joint preservation: a call for daily practice revival of realignment surgery and osteotomies around the knee

Opening- and closing-wedge high tibial osteotomy are comparable and early full weight bearing is safe with angular stable plate fixation: a meta-analysis

PURPOSE

The purpose of this study was to establish the gold standard for surgical technique, fixation, and rehabilitation for HTO in patients with unicompartmental knee osteoarthritis.

METHODS

Medline, Embase, and SPORTDiscus databases were searched up to April 2022. Included were (1) randomized controlled trials (RCTs) comparing opening-wedge HTO (owHTO) and closing-wedge HTO (cwHTO), (2) biomechanical studies and prospective patient studies comparing biomechanical and clinical results for plate fixators, and (3) RCTs comparing an early versus delayed full-weight-bearing (FWB) protocol.

RESULTS

The pooled results for the surgical technique showed no significant differences between owHTO and cwHTO for most PROMs on pain, activity, and risk for conversion to TKA. The cwHTO group showed a slightly better improvement in KOOS/WOMAC pain scores (4.51; 95% CI 1.18-7.85), and a significantly lower change in posterior tibial slope (p = 0.03). The pooled results for the fixation method showed the highest force at maximum failure for the Activmotion (Newclip Technics, France), Aescula (B. Braun Korea, Korea), 2nd generation Puddu (Arthrex Inc., USA), and TomoFix plate (Depuy Synthes, Switzerland). The pooled results for the rehabilitation protocol showed no significant differences between the early full-weight-bearing (FWB) group and the delayed FWB group for functional scores, complication rates, and delayed unions.

CONCLUSION

Both owHTO and cwHTO reduced pain and improved knee function. Locking plate fixation should be used for owHTO. An early FWB protocol has proven to be safe in patients with small corrections, no hinge fractures, and non-smokers.

LEVEL OF EVIDENCE

Level II.

Eight respectively nine out of ten patients return to sport and work after distal femoral osteotomy

PURPOSE

Distal femoral osteotomy (DFO) is a well-accepted procedure for the treatment of femoral deformities and associated symptoms including osteoarthritis, especially in younger and physically active patients in whom knee arthroplasty is undesirable. Still, there is an apparent need for evidence on relevant patient outcomes, including return to sport (RTS) and work (RTW), to further justify the use of knee osteotomy instead of surgical alternatives. Therefore, the purpose of the present study was to investigate the extent and timing of patients' RTS and RTW after DFO.

METHODS

This monocentre, retrospective cohort study included consecutive DFO patients, operated between 2012 and 2015. Out of 126 eligible patients (18-70 years, 63% female), all patients responded, and 100 patients completed the questionnaire. Median follow-up was 3.4 years (range 1.5-5.2). The predominant indication for surgery was symptomatic unicompartmental osteoarthritis and valgus or varus leg alignment caused by a femoral deformity. The primary outcome measure was the percentage of RTS and RTW. Secondary outcome measures included time to RTS/RTW, sports level and frequency, the median pre-symptomatic and postoperative Tegner activity score (1-10, higher is more active) and the postoperative Lysholm score (0-100, higher is better).

RESULTS

Out of 84 patients participating in sports preoperatively, 65 patients (77%) returned to sport postoperatively. Forty-six patients (71%) returned to sports within 6 months. Postoperative participation in high-impact sports was possible though less frequent compared to preoperative participation. Out of 80 patients working preoperatively, 73 (91%) returned to work postoperatively, of whom 59 patients (77%) returned within 6 months. The median pre-symptomatic Tegner activity score [4.0 (range 0-10)] was significantly higher (p < 0.01) than the reported Tegner score at follow-up [3.0 (range 0-10)]. The mean Lysholm score at follow-up was 68 (± 22). No significant differences were found between the osteoarthritis- and non-osteoarthritis group.

CONCLUSION

Eight out of ten patients return to sport and nine out of ten patients return to work after DFO. These are clinically relevant findings, because they further justify DFO as a surgical alternative to KA in young, active knee OA patients who wish to return to high activity levels.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.